1.Cefuroxime (1.5g IV) is acceptable as a prophylactic antibiotic in the peri-operative period. (There is no need to change to Cefotaxime). Maintain the patient on IV Cefuroxime until he/she can reliably go onto oral prophylactic antibiotics.

2.Patients who are sensitive to Penicillin should continue to get Ciprofloxacin (400 mg IV) as the peri-operative antibiotic. However, when it is clear during the operation that the spleen will be removed intravenous Clarithromycin (500 mg IV) should be added to Ciproxin.

3.Post operatively antibiotic prophylaxis should be given to all splenectomised patients. Penicillin V is still the best choice (Erythromycin can be in those who are allergic to Penicillin) for the following reasons:-

a.Penicillin V is a narrow spectrum antibiotic and it is probably not wise to subject patients to lifelong exposure to broad spectrum antibiotics like Amoxycillin.

b.Even Amoxycillin does not provide full cover for H-influenza and Meningococci and so may not be significantly better than Penicillin V.

4.The usual dosage for prophylaxis:

a.Penicillin V to be given 250 mg bd. If compliance is poor Penicillin V 500 mg daily is acceptable.

b.Erythromycin to be given 500 mg daily (fro those with penicillin allergy).

5.Duration of prophylaxis

a.Preferably life-long

b.Children up to 16 years of age (minimum)

c.Post splenectomy - 2/3 years (minimum)

d.Asplenia with underlying immunocompromise - lifelong.

6.Treatment of acute infection in a splenectomised patient.

a.All these patients require immediate hospitalisation.

b.A blood culture should be obtained before giving antibiotics if possible.

c.Two mega units of BenzylPenicillin given IV immediately, before transfer to hospital (if the patient is sensitive to Penicillin use Clarithromycin 500 mg IV).

d.Following admission, the patient should be started on IV Cefotaxime (or Chloramphenicol after consultation with the Microbiologist if the patient is sensitive to Cephalosporins as well as Penicillin).

IMMUNISATIONS

Vaccines to be avoided in Pregnancy and if the patient is undergoing Radiotherapy/chemotherapy.

1.Pneumococcal Immunisation

If splenectomy is a planned procedure pneumococcal vaccinations (Pneumovax II 0.5mls intramuscular injection) should be done 6 weeks preoperatively, if possible, or a minimum of two weeks preoperatively. If splenectomy was not planned, post operative immunisation should be done as soon as possible after the operation. Booster injections are given every 5 years.

2.HIB Immunisation

Haemophilus Influenza B immunisation (ACT-HIB powder for reconstitution with 0.5ml sterile water intramuscular injection) is done before the patient leaves the hospital. The need for boosters is, however, not clear.

3.Meningococcal Immunisation

Because of the short lived protection provided routine use of meningococcal immunisation is not recommended except when the patient is travelling to an area with a high risk of meningococcal infection.

4.Influenza Immunisation

Yearly influenza vaccination may be helpful to splenectomised patients in reducing the risk of influenza and therefore secondary infections.

OTHER RECOMMENDATIONS

1.The patient should be fully made aware of the fact that he is lacking a spleen and the implications. He may also be provided with a card mentioning this as well as mentioning the status of immunisation provided.

2.A supply of antibiotics should be given to the patient (probably Amoxycillin) and he should be advised to start the antibiotic as soon as there is any sign of an infection setting and contact his GP as soon as possible.

3.The patient is advised to get specific advice before travelling abroad. Especially regarding the following:

a.Anti-malarial prophylaxis

b.Meningococcal vaccination.

c.Take a supply of antibiotic along.

There is no need for routine anti fungal cover. Beware of transient (up to 4/52 post-op) rise in Prothrombin time (PTT) and WBC counts.

These guidelines were drawn up following consultation with Dr. Webb, Consultant Bacteriologist, RGHT. They have been discussed in the Thoracic Surgical Audit Meeting on the 10/03/99 and were agreed upon for implementation.